Dear Mr McLoughlin Mark Anthony Athias Inquest I am writing to you in response to your Regulation 28 report dated 28 January 2022, following the inquest into the death ofMark Anthony Athias, which you conducted on 27 January 2022. First, and on behalf ofall the staff at Exemplar Health Care and particularly Copperfields Care Home, I would like to say how deeply saddened we all were by Mr Athias' tragic death. Your report raises five matters that cause you concern and I shall take each in turn.
1. The nursing home did not have sterile replacement catheters in stock, despite being aware that Mr Athias had difficulties with his catheter, which had necessitated it being replaced twice in the previous weeks. The mistakes made in ordering placements had not been detected by managers in the nursing home. You heard evidence from , Head of Quality for Exemplar Health Care Services that following Mr Athias' death Exemplar Health Care's catheter policy was updated to reflect the importance ofretaining sufficient stocks ofcatheters in all Exemplar Health Care homes. You were provided with a copy of the updated policy and your attention was drawn to the following paragraph: "It is essential to ensure that the home retains sufficient stocks ofcatheters, lubricating gel, sterile catheter packs, drainage systems, securing systems and stands. Ensure sufficient stock levels are available· to accommodate both planned and unplanned replacement andfactor in emergency changes i. e. ifthe catheter is known to be problematic" explained that, at the time of Mr Athias' placement at Copperfields, all ofthe care documentation was paper based. This meant stock was ordered by a tally system, with the need Copperfields Health Care Limited, Company Number: 11731796 Registered office t ,, 1
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for the nurses on duty to ensure that a visual observation was undertaken, and stock ordered or, if the observation was undertaken out of hours, then the need for further stock to be ordered was communicated in the unit diaries in order for it to be ordered the following day. You were provided with written evidence from Nurse that she recognised that the catheter stock was insufficient during an out ofhours shift on 2 July 2021, and she requested that further catheters be ordered. Unfortunately, due to a communication error this request was not actioned. explained that, following Mr Athias' death, she personally reviewed all incidents across the Exemplar Health Care organisation and found no evidence ofa similar incident occurring, either before or since. She explained that the lack of sterile catheter was therefore an unfortunate, one-off communication error. Ms also explained that, shortly after Mr Athias' death, weekly stock checks were implemented at Copperfields in order to ensure a sufficient level of stock is maintained at all times. This new system is working well. Following Mr Athias' death, Exemplar Health Care has also implemented an Electronic Medication System ("EMAR"). This means that stock level is visible on the EMAR system at all times and stock levels can be viewed by the nurses on EMAR laptops, and remotely by Clinical Nurse Managers, Heads of Care, the Registered Home Managers and the central support service 24 hours a day. This has resulted in far more overview ofstock at all levels of seniority and removes the risk of a CO!Jllllunication error leading to an absence ofequipment such as occurred in Mr Athias' case. The EMAR system also has a Dashboard that flags an alert in the event any stock is running low. The levels of stock are therefore no longer dependent on visual assessment although, as explained by Ms , weekly visual stock checks still take place. The EMAR system also enables the central support team to undertake a weekly dashboard review as a further check on stock levels across the organisation. In addition to the wider organisational changes explained above, Copperfields has put in place a "3 step check" system in order to ensure monitoring ofcatheters as follows:
1. Each resident with a catheter in situ has stock located within their room which is visually checked on a daily basis by the team leaders. This means that the team leaders can reassure themselves that there are enough catheters for each individual resident (rather than relying on a general level of stock for all residents).
2. A back up stock ofcatheters is stored in the storeroom with a minimum ofthree catheters for each resident.
3. Stock level is recorded in each unit's individual diary and this is reviewed on a daily basis as part ofthe daily handover. The written record requires sign off after each catheter check and so an individual Registered Nurses take personal responsibility for the accuracy. Copperfields delivered shared learning with the nursing staff following Mr Athias' death which highlighted the other avenues available to access catheters in the community. In addition, following the implementation ofthe EMAR system at Copperfields in February 2022, all staff were provided with several weeks ofEMAR training and have access to 24 hours a day support from the EMAR team. The nurses and management team have been trained to review the stock

levels on EMAR on a daily basis. The Copperfields staff also have access to an on-call system to the home management staff 24 hours a day should any issues arise.
2. The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate. This hindered any assessment of his urinary problems. The managers in the nursing home had not noticed the inadequacy of such records. Exemplar Health Care has protocols for recording fluid balance (including input and output), and a supporting fluid and nutrition policy. These policies were in place at the time ofMr Athias' stay at Copperfields; however, it is recognised that Mr Athias' contemporaneous records were not consistently kept, and this had not been recognised by the management team at the time. You heard evidence from Ms that specific catheter related training was delivered at Copperfields by an experienced Quality Manager following Mr Athias' death. Ms

explained that the feedback following this training was that the nursing staff at Copperfields were knowledgeable and informed in respect of catheterisation and catheter care but were very pleased to undertake appropriate refresher training. In addition, the importance ofrecording fluid intake as well as output was highlighted to the care team in a shared learning presentation, emphasising what steps were to be taken in order to prevent any future similar occurrences. Further workshops and coaching sessions have also been undertaken by various experienced Quality Managers in order to support staff to create, implement and monitor more thorough and unambiguous care plans. In the first instance this support was focussed on the documentation for service users who utilised catheters, however the workshops have now been undertaken in relation to all service users and included general sessions on record keeping anddocumentation. You heard evidence from Ms that significant management change has now taken place at Copperfields since Mr Athias' death. A new Registered Home Manager and new Clinical Nurse Manager are now in place. In addition, a second full time Clinical Nurse Manager and a full time Head of Care have been employed. This is to ensure that there is additional management resource in order to support the home and, particularly, to ensure that there is a Clinical Nurse Manager on site at weekends and out of hours. I set out in an appendix to this letter the previous and current management structure at Copperfields. In addition to these management changes, specific steps have also been taken to ensure greater management overview, and quality assurance, ofrecord keeping and documentation. During Mr Athias' residence at Copperfields the relevant governance processes (EQA- Exemplar Quality Assurance) were paper based. However, the majority ofthe EQA processes have now been moved to a digital platform. The individual team leaders have been trained that they are responsible for ensuring that there are no gaps in the supplementary documentation, that all documentation is complete before the end oftheir shifts and that this is reported to the unit managers, who in turn report it in a daily "take 20 meeting". This is then documented in the EQA electronic record. Quality assurance reviews are also undertaken by:
1. A daily manager walk around;
2. A clinical manager walk around which is undertaken daily ; and

3. A daily "take twenty" meeting this involves the Home manager, Clinical Nurse Manager and the Unit Manager or registered general nurse managing the unit on the day. The results of these quality assurance reviews can be reviewed remotely on the EQA systems, which can be access via PC, Laptop, Tablet or smart phone. The EQA processes enable managers to monitor in "real time" (either remotely or in person) the supplementary records and any "actions required" as these are now recorded digitally.
3. The handover record for 2nd July 2021 was missing, having allegedly been overwritten. The managers in the nursing home did not appreciate this until an adult safeguarding investigation was underway. You heard evidence from Ms that Exemplar Health Care had changed its system to use word templates across the entire organisation. It is therefore no longer possible for documents such as handovers to be overwritten. In addition, each handover is now saved electronically in a specific month document file and a copy is printed off and retained in the management office at Copperfields in paper form with a date tracker. In the management office, three months ofpaper copies are saved in files for each unit. After the three-month period has elapsed the paper copies are archived in the storage room. Prior to archiving, a monthly check takes place to ensure that there are no missing days and the individual checker this is completed by the Home Manager and Clinical Nurse Manager who signs to confirm that they have been reviewed and all relevant paper copies are present. This method ensures that all documentation is accessible both electronically and in paper form and there is no longer any possibility ofa document such as a handover being overwritten, and the content lost.
4. In order to ensure instructions were complied with, and without checks to ensure that contemporaneous records required to be kept were actually being maintained, there is a risk deficient record keeping could continue. I have detailed above the relevant management structure changes and quality assurance systems in place to ensure that all record keeping is appropriate and accurate. In summary:
1. Exemplar Health Care has introduced an electronic system which is accessible remotely and allows oversight from the central clinical team.
2. Exemplar Health Care has implemented a daily clinical walk around by a nurse which provides quality assurance and traceability. This walk around is then signed off by the Home Manager or Head of Care.
3. Exemplar Health Care has implemented weekly EMAR feedback on each home.
4. Exemplar Health Care has implemented a monthly compliance feedback.
5. Shared learning has taken place at Copperfields.
6. Defensible documentation training has taken place at Copperfields.
7. A 24-hour management structure is now in place at Copperfields.
8. It is now explicitly part ofthe team leaders' roles that they are responsible for reviewing and quality assuring supplementary records.

9. Copperfields has implemented monthly auditing of supplementary and care files and findings are discussed with individual unit managers.
10. Daily electronic saving ofhandovers takes place and printed copies are stored in the Copperfields management office.
11. Daily monitoring of EMAR dashboards for stock levels takes place. Exemplar Health Care is confident that the processes outlined above have resulted in all clinical instructions being followed, appropriate record keeping being undertaken and regular, appropriate quality assurance taking place.
5. Managers of nursing homes should make checks sufficiently often to ensure the records required to be kept actually exist, and that they are preserved, so as to facilitate an analysis of trends in the medical conditions of patients in the care of the nursing home. I have set out above the various processes that have been implemented to ensure that the management team at Copperfields, and across Exemplar Health Care, review and quality assure records. I am confident that appropriate records are being kept and retained. In addition, Copperfields has a weekly governance meeting where trends can be monitored and further actions undertaken in response to any audit findings, untoward incidents or "near miss" events. These trends are also recorded as part of the clinical statistics for Copperfields which are reported every period to the Exemplar Health Care compliance team. The compliance team is therefore able to review any trends across the whole ofthe organisation and identify any anomalies for an individual care home. I would like to take the opportunity to assure you that Exemplar Health Care seeks to learn from all untoward incidents and absolutely recognises that Mr Athias 1 death was the most serious type ofsuch incidents. As outlined in the evidence of Ms during the inquest and in the summary above, Exemplar Health Care has already taken learning from Mr Athias' extremely sad death and will continue to do so.